Lee Jen-Kuang, Hung Chi-Sheng, Huang Ching-Chang, Chen Ying-Hsien, Chuang Pao-Yu, Yu Jiun-Yu, Ho Yi-Lwun
Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan.
Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
J Med Internet Res. 2019 Jan 31;21(1):e12790. doi: 10.2196/12790.
Telehealth programs are generally diverse in approaching patients, from traditional telephone calling and texting message and to the latest fourth-generation synchronous program. The predefined outcomes are also different, including hypertension control, lipid lowering, cardiovascular outcomes, and mortality. In previous studies, the telehealth program showed both positive and negative results, providing mixed and confusing clinical outcomes. A comprehensive and integrated approach is needed to determine which patients benefit from the program in order to improve clinical outcomes.
The CHADS-VASc (congestive heart failure, hypertension, age >75 years [doubled], type 2 diabetes mellitus, previous stroke, transient ischemic attack or thromboembolism [doubled], vascular disease, age of 65-75 years, and sex) score has been widely used for the prediction of stroke in patients with atrial fibrillation. This study investigated the CHADS-VASc score to stratify patients with cardiovascular diseases receiving a fourth-generation synchronous telehealth program.
This was a retrospective cohort study. We recruited patients with cardiovascular disease who received the fourth-generation synchronous telehealth program at the National Taiwan University Hospital between October 2012 and June 2015. We enrolled 431 patients who had joined a telehealth program and compared them to 1549 control patients. Risk of cardiovascular hospitalization was estimated with Kaplan-Meier curves. The CHADS-VASc score was used as the composite parameter to stratify the severity of patients' conditions. The association between baseline characteristics and clinical outcomes was assessed via the Cox proportional hazard model.
The mean follow-up duration was 886.1 (SD 531.0) days in patients receiving the fourth-generation synchronous telehealth program and 707.1 (SD 431.4) days in the control group (P<.001). The telehealth group had more comorbidities at baseline than the control group. Higher CHADS-VASc scores (≥4) were associated with a lower estimated rate of remaining free from cardiovascular hospitalization (46.5% vs 54.8%, log-rank P=.003). Patients with CHADS-VASc scores ≥4 receiving the telehealth program were less likely to be admitted for cardiovascular disease than patients not receiving the program. (61.5% vs 41.8%, log-rank P=.01). The telehealth program remained a significant prognostic factor after multivariable Cox analysis in patients with CHADS-VASc scores ≥4 (hazard ratio=0.36 [CI 0.22-0.62], P<.001).
A higher CHADS-VASc score was associated with a higher risk of cardiovascular admissions. Patients accepting the fourth-generation telehealth program with CHADS-VASc scores ≥4 benefit most by remaining free from cardiovascular hospitalization.
远程医疗项目在对待患者的方式上通常多种多样，从传统的电话呼叫、短信到最新的第四代同步项目。预先设定的结果也各不相同，包括高血压控制、血脂降低、心血管结局和死亡率。在先前的研究中，远程医疗项目显示出了积极和消极的结果，提供了混杂且令人困惑的临床结局。需要一种全面综合的方法来确定哪些患者能从该项目中获益，以改善临床结局。
CHADS-VASc（充血性心力衰竭、高血压、年龄>75岁[加倍]、2型糖尿病、既往卒中、短暂性脑缺血发作或血栓栓塞[加倍]、血管疾病、65 - 75岁年龄以及性别）评分已被广泛用于预测心房颤动患者的卒中。本研究调查了CHADS-VASc评分，以对接受第四代同步远程医疗项目的心血管疾病患者进行分层。
这是一项回顾性队列研究。我们招募了2012年10月至2015年6月在台湾大学医院接受第四代同步远程医疗项目的心血管疾病患者。我们纳入了431名参加远程医疗项目的患者，并将他们与1549名对照患者进行比较。用Kaplan-Meier曲线估计心血管住院风险。CHADS-VASc评分用作综合参数来对患者病情严重程度进行分层。通过Cox比例风险模型评估基线特征与临床结局之间的关联。
接受第四代同步远程医疗项目的患者平均随访时间为886.1（标准差531.0）天，对照组为707.1（标准差431.4）天（P<0.001）。远程医疗组基线时的合并症比对照组更多。较高的CHADS-VASc评分（≥4）与较低的无心血管住院估计率相关（4-6.5%对54.8%，对数秩检验P = 0.003）。CHADS-VASc评分≥4且接受远程医疗项目的患者因心血管疾病入院的可能性低于未接受该项目的患者（61.5%对41.8%，对数秩检验P = 0.01）。在CHADS-VASc评分≥4的患者中，经过多变量Cox分析后，远程医疗项目仍然是一个显著的预后因素（风险比=0.36[可信区间0.22 - 0.62]，P<0.001）。
较高的CHADS-VASc评分与心血管入院风险较高相关。CHADS-VASc评分≥4且接受第四代远程医疗项目的患者通过避免心血管住院获益最大。
